Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
ECPR
1 Plays7 months ago
In this episode, Dr. Sergio Zanotti discusses ECPR–Extracorporeal Cardiopulmonary Resuscitation. ECPR is still be considered a niche therapy, but its relevance and availability are increasing. He is joined by Dr. Adam Green, a practicing intensivist at Cooper University Health Care and an Associate Professor of Medicine at Cooper Medical School of Rowan University (CMSRU). Dr. Green is the director of research for the division of Critical Care and has authored over 50 peer-reviewed publications. He has been part of the ECMO team at Cooper since its inception.
Additional resources:
Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest. The Lancet Respiratory Medicine 2025: https://www.sciencedirect.com/science/article/pii/S2213260025001225
Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest. JAMA 2022: https://jamanetwork.com/journals/jama/fullarticle/2789313
Association between increasing institutional experience with ECPR and outcomes in patients with out-of-hospital cardiac arrest: A nationwide multicenter observational study in Japan (the JAAM–OHCA registry) RESUSCITATION 2025: https://www.resuscitationjournal.com/article/S0300-9572(24)00862-1/fulltext
Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Eng J of Med 2023: https://www.nejm.org/doi/full/10.1056/NEJMoa2204511
Books mentioned in this episode:
The Perfect Predator: A Scientist’s Race to Save Her Husband from a Deadly Superbug. By S. Strathdee and T Patterson: https://amzn.to/3Hxjmez
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Mechanically Circulatory Support in Critical Care
00:00:32
Speaker
The interest in and use of mechanically circulatory support, including extracorporeal membrane oxygenation, continues to grow rapidly in critical care medicine.
00:00:43
Speaker
Today, we will focus our discussion on ECPR, Extracorporeal Cardiopulmonary Resuscitation.
00:00:50
Speaker
It may still be considered a niche therapy, but its relevance and availability are increasing.
What is eCPR and its importance?
00:00:56
Speaker
Our guest is Dr. Adam Green, a practicing intensivist at Cooper University Healthcare and an associate professor of medicine at Cooper Medical School of Rowan University.
00:01:07
Speaker
Dr. Green is a director of research for the Division of Critical Care and has authored over 50 peer-reviewed publications.
00:01:14
Speaker
He has been part of the ECMO team at Cooper since its inception.
00:01:18
Speaker
Dr. Green is a recognized clinical educator and has received multiple teaching awards.
00:01:23
Speaker
Adam, welcome to Critical Matters.
00:01:25
Speaker
Thank you, Dr. Zanadi.
00:01:26
Speaker
Thank you for having me.
00:01:28
Speaker
I was excited and honored for the invite.
00:01:31
Speaker
Well, first rule of critical matters, you've got to call me Sergio, not Dr. Zanotti.
00:01:35
Speaker
Oh, I know, I know.
00:01:36
Speaker
It's tough, it's tough.
00:01:37
Speaker
Yeah.
00:01:38
Speaker
You know, I often joke that you left Cooper right before I came, and I think it's because you knew I was coming, and you said, I need to get out of here.
00:01:47
Speaker
Well, what I hear is that you only accepted because I had left, but that's another story.
00:01:51
Speaker
Maybe, maybe, maybe.
00:01:54
Speaker
So as a starting point, I would like to ask you, why do you think this topic of eCPR should be of interest for intensivists?
00:02:03
Speaker
Yeah, I think it's tough.
00:02:05
Speaker
I think, um,
00:02:06
Speaker
When I think about ECMO, and trust me, when I think about my fellowship, we had ECMO.
00:02:13
Speaker
It was mostly decided by CT surgery, and we managed the patients, but for the most part, it was away from us.
00:02:21
Speaker
And I think about how many cases were done then versus now, and there truly has just been an explosion of ECMO in general.
00:02:28
Speaker
And I was looking at ELSO, you know, they publish quarterly or twice a year stats of just how many runs are done, how many centers.
00:02:37
Speaker
And certainly there was a spike during COVID, but it really predated COVID and continues.
00:02:43
Speaker
And I think we're at almost 600 centers and over 21,000 ECMO runs in adults a year.
00:02:51
Speaker
So what that tells me is that even if you're not at an ECMO center,
00:02:55
Speaker
Like it's coming, it's expanding, it's becoming more and more, you said niche, and I think maybe 10 years from now we'll look at it differently.
00:03:04
Speaker
So at least for VB, you should know when to transfer or refer your patients.
00:03:09
Speaker
Probably for VA, well, obviously you're not going to transfer someone for eCPR.
00:03:14
Speaker
I think the more you know about it, the better it is.
00:03:18
Speaker
Perfect.
00:03:20
Speaker
And as we start with some general concepts, could you tell us a little bit more detail?
00:03:24
Speaker
What is eCPR?
00:03:26
Speaker
Yeah, I mean, I think you stole the words exactly, which is this extracorporeal cardiopulmonary resuscitation.
00:03:32
Speaker
So it's exactly what it sounds like.
00:03:34
Speaker
It's using ECMO to support circulation and oxygenation during refractory cardiac arrest.
00:03:40
Speaker
So it's cannulating someone for ECMO while they're undergoing CPR.
00:03:46
Speaker
Technically for ELSO, it's or within 20 minutes of ROSC, but it's that idea of using ECMO to promote ROSC.
00:03:55
Speaker
So it really is the application of ECMO within the cardiac arrest situation.
00:04:01
Speaker
And you did mention something that is very important.
00:04:04
Speaker
You mentioned the refractory cardiac arrest.
00:04:06
Speaker
So this is not something that we just apply to anybody who has VT or cardiac arrest, right?
00:04:13
Speaker
It's for certain cases, correct?
00:04:14
Speaker
Correct.
00:04:15
Speaker
Yeah, and I'm sure we'll jump into some of the inclusion and exclusion criteria, but I think, and this is going to be, this is probably a theme throughout the next hour of the conversation, which is you always prefer...
00:04:29
Speaker
ROSC through normal ACLS.
00:04:31
Speaker
I never want to put someone on eCPR.
00:04:33
Speaker
I would rather them develop ROSC without the use of eCPR.
00:04:37
Speaker
And that a lot of that has to do with just the complications associated with it and the altering of physiology when you add kind of counter current flow.
00:04:48
Speaker
So I always want ROSC, but I also don't want to wait too long.
00:04:52
Speaker
So it's understanding that exact moment of when to cannulate.
00:04:56
Speaker
So
00:04:57
Speaker
The earlier the better, but not too early if you can get ROSC.
00:05:00
Speaker
I don't know if that makes sense.
00:05:02
Speaker
Yeah, absolutely.
00:05:03
Speaker
But that I certainly would highlight.
00:05:04
Speaker
Yeah.
00:05:05
Speaker
And is there a distinction in your mind in terms of eCPR and out-of-hospital cardiac arrest versus intra-hospital cardiac arrest?
00:05:13
Speaker
Obviously, the literature is evolving, but even in your practice, do you make a distinction?
00:05:18
Speaker
Yeah, so we have different criteria.
00:05:19
Speaker
So first off, they both are adults.
00:05:24
Speaker
They both need to have witness arrest with immediate CPR.
00:05:27
Speaker
So whether that's in the hospital or it's bystander if it's out of hospital.
00:05:31
Speaker
And we tend to be a little more strict with out of hospital.
00:05:34
Speaker
So I really want it to be a V-fib or VT arrest.
00:05:39
Speaker
We will sometimes cannulate PEA if there's clear, purposeful movement.
00:05:44
Speaker
So when you're doing compressions, they're reaching for the tube.
00:05:48
Speaker
But I need to be pretty convinced.
00:05:49
Speaker
Now, that's different for in-hospital cardiac arrest, where it could be a PEA.
00:05:53
Speaker
I think it's immediate reversible.
00:05:55
Speaker
I understand why they're arresting.
00:05:57
Speaker
And I guess the cutoffs, I would say, is three defibs.
00:06:01
Speaker
That's kind of the time where we pull the trigger.
00:06:03
Speaker
Or 15 minutes of ACLS.
00:06:05
Speaker
That's the time when we'll decide to start cannulation.
00:06:08
Speaker
So that's how you're defining refractory cardiac arrest,
Understanding Refractory Cardiac Arrest
00:06:13
Speaker
right?
00:06:13
Speaker
Either they got three episodes of defibrillated three times without success or temporary success, or you've been at it for 15 minutes.
00:06:22
Speaker
So really, it's not something that happens immediately, but that happens after CPR has been initiated.
00:06:30
Speaker
That's right.
00:06:31
Speaker
That's right.
00:06:31
Speaker
And if you just think about the timing of it, like it's, I kind of wish, I wish you would be, you know, I could take you and show you a video and like put you in the scene, but you know, patients coming in, ideally it's for out of hospital, it's less than 30 minutes between when they arrest and when they actually hit the ER and it takes time to mobilize your team.
00:06:50
Speaker
And so I think we'll talk about studies and it's really, you want that low flow or the CPR time to be as low as possible.
00:06:59
Speaker
And usually neurological, uh,
00:07:01
Speaker
recovery is in the realm of 40 minutes or so.
00:07:04
Speaker
So if it takes them less than 30 minutes to get there, you have 15 or 20 minutes to pull the trigger and get them on.
00:07:09
Speaker
And the procedure itself takes time, right?
00:07:12
Speaker
So it's, once again, that balance of looking at the chart, making sure there's no contraindications, deciding to do it, get your whole team ready, and then actually cannulating.
00:07:23
Speaker
And so it's split second.
00:07:25
Speaker
You have to kind of, you have to be able to make the decision quickly.
00:07:30
Speaker
And I think, Adam, that when we talk about cardiac arrest outside of the context of ECPR, we usually talk about
00:07:39
Speaker
shockable rhythms, non-shockable rhythms.
00:07:41
Speaker
We might talk about downtime.
00:07:43
Speaker
We might talk about bystander CPR.
00:07:46
Speaker
We might talk about concepts like ROSC as part of what we're describing clinically.
00:07:54
Speaker
But it seems that three words or three terms that are very important in describing and understanding the cardiac arrest itself when it comes to eCPR are refractory,
00:08:04
Speaker
no flow time, and low flow time, correct?
00:08:08
Speaker
Right.
00:08:09
Speaker
Could you expand on those?
00:08:11
Speaker
Yeah, so low flow would be no CPR.
00:08:13
Speaker
So for eCPR, that needs to be zero.
00:08:17
Speaker
If it's a young person who's found down and a bystander doesn't know when, they don't feel pulse, and they start CPR, that's a no-go.
00:08:25
Speaker
So there's no flow time there.
00:08:28
Speaker
When we use the term low flow, that would either be manual compressions by a
00:08:35
Speaker
A healthcare provider or a bystander or a Lucas device would be low flow.
00:08:41
Speaker
And downtime is generally used, I guess, from all of that combined.
00:08:46
Speaker
It's a time between when they have the arrest and then when you actually get ROSC or ECMO flow, if it's eCPR.
00:08:52
Speaker
Excellent.
00:08:53
Speaker
Now, this is obviously, as you mentioned, also a growing area of interest, a growing application of ECMO in the cardiac arrest environment.
00:09:05
Speaker
What does the literature say?
00:09:06
Speaker
I know there are some studies out there.
00:09:08
Speaker
Could you just give us maybe at a very high level some of your insights or comments in terms of what's been studied and what's out there?
00:09:15
Speaker
Yeah, how much time you want to talk about it.
00:09:16
Speaker
So I think there's a handful, and you'll notice all of the publication dates are 2020 and onward.
00:09:23
Speaker
So it's all recent stuff, right?
00:09:25
Speaker
There's probably three main RCTs.
00:09:28
Speaker
The largest one is through the Prague Group, which had...
00:09:32
Speaker
Out of hospital cardiac arrest, it was field ACLS, essentially stay and play versus pick them up and go versus eCPR at the hospitalization.
00:09:41
Speaker
And for the most part, and I would say all three studies, and I'm happy to go into detail if you'd like.
00:09:47
Speaker
all show that eCPR outperforms ACLS in this population in terms of survival.
00:09:53
Speaker
And really the outcome we care about is neurological recovery.
00:09:56
Speaker
So CPC of one or two.
00:09:58
Speaker
And when we are looking at numbers, it varies.
00:10:00
Speaker
Some of the studies are pretty small, but I would say maybe 30%, 20 to 30% of eCPR.
00:10:04
Speaker
And then ACLS is less than that.
00:10:06
Speaker
So we're
00:10:10
Speaker
not talking about high survivable, right?
00:10:12
Speaker
So those are like the RCTs.
00:10:14
Speaker
And then I think there's two major registry studies.
00:10:17
Speaker
So one is through this Japanese registry that had over 1600 patients, and they showed that survival with CPC of one or two to be 14%.
00:10:25
Speaker
So really low, right?
00:10:27
Speaker
So it sounds it's, you know, fun and sexy technology, but still, we're not talking about great outcomes in the majority of patients.
00:10:35
Speaker
And in that study, I think it's worth highlighting that the time to eCPR was under an hour, but in the 50, 55-minute range.
00:10:44
Speaker
And complications happen in almost a third of the patients.
00:10:47
Speaker
And I think ELSO reports something similar.
00:10:49
Speaker
I think maybe it's better 20 or 30 percent say that the patient survived that had eCPR done.
00:10:55
Speaker
And in terms of guidelines, what are the current guidelines recommending for eCPR?
00:11:02
Speaker
Yeah, I think that's hard.
00:11:06
Speaker
I'm not sure.
00:11:07
Speaker
You know, ELSO has some guidelines.
00:11:09
Speaker
There's some other associated guidelines.
00:11:12
Speaker
I think generally it's going to be a healthy person that's less than 70 years old that has no major comorbidities.
00:11:19
Speaker
So we're taking people on dialysis, people with NSAID heart disease, people with oxygen requirements or malignancy generally are not candidates.
00:11:30
Speaker
And they're saying the same thing.
00:11:32
Speaker
You want time from ER to, or from arrest to ER to less than 30 minutes.
00:11:37
Speaker
And you want time to cannulation somewhere around 45 minutes if you can.
Patient Selection Criteria for eCPR
00:11:41
Speaker
The other thing that's at play that we look at is end title.
00:11:44
Speaker
So if you have a consistent end title less than 10 during, during arrest, that is a reason to not cannulate.
00:11:50
Speaker
That's a marker of, of poor, of poor neurological outcomes.
00:11:55
Speaker
So really it's about patient selection.
00:11:58
Speaker
But I thought it was important to start with a brief discussion at a high level, and we'll add these references to the show notes, because there is some studies.
00:12:08
Speaker
There is data that's emerging and that we should be paying attention, right?
00:12:12
Speaker
Even if you're not doing eCPR today in your institution, you might soon.
00:12:17
Speaker
So
00:12:18
Speaker
When we talk about practical considerations, now let's dive a little bit deeper into the indications for eCPR.
00:12:24
Speaker
Maybe, and you mentioned some of them, but could you just maybe describe the ideal patient for you first?
00:12:29
Speaker
Yeah.
00:12:31
Speaker
Sure.
00:12:32
Speaker
And I should, I guess, you know, surgery, I should, I should highlight that.
00:12:35
Speaker
Like think when you talk about the registry studies, you need to remember that these are generally patients that made it onto ECMO successfully, right?
00:12:44
Speaker
There are probably patients that they attempt to cannulate that never make the registry because they never actually were on ECMO and those clearly are negative outcomes, right?
00:12:54
Speaker
So be cautious when you look, because 30% sounds pretty good.
00:12:58
Speaker
And, and also same kind of the other caveat to think about, and I'll get to your question in a second is when you look at some of the RCTs, these are excellent centers, you know, the Prague group, these are, these are, these are groups that have the timing down, have the equipment ready, have the resources and are really good at what they do.
00:13:17
Speaker
And even those, um, and, and don't get me wrong, I'm an ECMO enthusiast, right?
00:13:21
Speaker
So I want to be doing ECMO whenever we possibly can.
00:13:24
Speaker
You just have to be really careful because even the best, um,
00:13:28
Speaker
the outcomes I wish were better.
00:13:30
Speaker
So if I think about, and I think it all comes down to patient selection.
00:13:33
Speaker
So if I think about the ideal patient, who is it?
00:13:35
Speaker
It's someone who is having this refractory cardiac arrest that CPR has failed, conventional CPR has failed, and it's going to continue to fail, but we're early enough in the course.
00:13:45
Speaker
And so you're able to decide once again, that this is someone who's not going to get ROSC and needs to be heavy CPR.
00:13:52
Speaker
Ideally, it's a shockable, initial shockable rhythm.
00:13:55
Speaker
Ideally, it's of some sort of reversible
00:13:58
Speaker
process.
00:13:59
Speaker
So that's generally going to be some sort of cardiac etiology, right?
00:14:04
Speaker
So someone with a STEMI who then has a V-fib arrest, that's a perfect candidate.
00:14:08
Speaker
Someone who has a large PE and obstructive shock and arrests, and you know that you can establish flow, take them to the lab, do a thrombectomy, that's a perfect candidate.
00:14:18
Speaker
A young person with myocarditis who you think you can support them and that viral myocarditis is going to improve and get better, that's a good candidate.
00:14:27
Speaker
But someone who has congenital heart disease or a bad malignancy that's leading to some sort of complication that leads to cardiac arrest, those are not good candidates.
00:14:40
Speaker
I think that's how I would think about it, is someone who's got a reversible process that you can get early on and that has good high-quality CPR up until cannulation.
00:14:51
Speaker
Excellent.
00:14:51
Speaker
And in terms of a of contraindications, could you maybe talk about absolute versus relative contraindications?
00:14:58
Speaker
You mentioned a lot of things that are very useful.
00:15:00
Speaker
We can we can repeat those.
00:15:01
Speaker
But just how how do you approach this when you get called down to make that decision?
00:15:06
Speaker
Yeah, you can quote me on this, or maybe I shouldn't be quoted, but I sometimes feel like evidence-based medicine is the gold standard, but that anecdotal medicine is better, right?
00:15:17
Speaker
And we've all had those personal experiences where we're like, I know the literature says this, but I'm going to do this instead.
00:15:23
Speaker
And I'm not advocating for that, but I think that using this term absolute is hard, right?
00:15:29
Speaker
Because there's always someone who maybe has an absolute, and you're like, actually, that was a good idea.
00:15:34
Speaker
And I can give you a story that I think is that after I kind of go through these that I think rings true for that.
00:15:41
Speaker
But some of the generally speaking Napsu Chondra indication would be a patient with either tamponade, so large pericardial effusion you're not going to want to put on that can make things much worse.
00:15:55
Speaker
Someone that has free fluid and you think has a perforated viscous or has a ruptured aneurysm, for example, AAA, you're not going to want to put them.
00:16:02
Speaker
on.
00:16:02
Speaker
So someone that's bleeding from hemorrhagic shock is not going to be a candidate.
00:16:06
Speaker
And then some of the relative things are those end stage diseases we talk about, heart, lung, kidney, liver, right?
00:16:14
Speaker
Metastatic malignancy is another one.
00:16:16
Speaker
Although, you know, there's always scenarios where when you think about VV ECMO, you say you shouldn't put someone on with cancer.
00:16:24
Speaker
Yet, I know we had a patient who was
00:16:29
Speaker
was incredibly hypoxic.
00:16:30
Speaker
We put him on and he got chemotherapy, his lungs got better and he got off ECMO and he went on living and was able to get the treatment, you know, and so there's always exceptions.
00:16:40
Speaker
Then title I mentioned, I think that's a big one.
00:16:43
Speaker
And then probably the biggest is if there isn't a cannulator, you don't have perfusionists.
00:16:47
Speaker
If someone, if they're far away, that's someone, you know, it is going to be more than 60 minutes before you get flow.
00:16:53
Speaker
That's someone you should walk away from.
00:16:54
Speaker
Don't do the procedure just because you can.
00:16:57
Speaker
Absolutely.
00:16:58
Speaker
And you mentioned, and I'm going to jump back to the indications.
00:17:04
Speaker
So you mentioned some clinical scenarios like VT, refractory VT with ischemia, somebody with an acute MI, acute pulmonary embolism, myocarditis.
00:17:16
Speaker
The other one that I have never seen or haven't used it for that, but I've seen a report in the literature, which obviously affects younger patients sometimes, is drug overdoses.
00:17:26
Speaker
Any comments on that, Adam?
00:17:29
Speaker
Yeah, that's tough.
00:17:33
Speaker
That's tough.
00:17:34
Speaker
I don't know if we have done that.
00:17:39
Speaker
But it's certainly possible, I think.
00:17:41
Speaker
You know, a component of this that I haven't mentioned that goes into the decision, whenever you cannulate anyone for ECMO, is what is the social support?
00:17:50
Speaker
Who's there to consent?
00:17:51
Speaker
This is not a minor procedure, right?
00:17:53
Speaker
So we really like to have someone we're speaking to.
00:17:56
Speaker
And especially because you can put them on, you're supporting their organs, they have severe neurological injury, then you're faced with a hard decision of how do you remove them from ECMO.
00:18:06
Speaker
And if you don't have someone to speak to,
00:18:09
Speaker
you get into a really dicey territory, right?
00:18:13
Speaker
So not saying that people with drug overdose don't have family.
00:18:17
Speaker
Of course they do.
00:18:17
Speaker
I'm just saying it increases the chance that, that, that, um,
00:18:22
Speaker
that you could get yourself into trouble.
00:18:24
Speaker
So I'm sure I could imagine a scenario of a cocaine overdose leading to V-fib leading to cannulation.
00:18:30
Speaker
We just haven't we haven't seen that.
00:18:32
Speaker
And maybe I should qualify that a little bit better.
00:18:35
Speaker
I think the case reports that I have read are really cardiac drugs.
00:18:38
Speaker
Like if you have a massive beta blocker overdose or calcium channel blocker, you can be in refractory shock, right?
00:18:44
Speaker
And have a cardiac arrest.
00:18:46
Speaker
And that's where maybe that has been reported.
00:18:49
Speaker
But I hear that's what you're saying, and that's why I wanted to ask.
00:18:54
Speaker
Yep.
00:18:56
Speaker
It's not coming out yet, but we wrote a little editorial.
00:18:58
Speaker
There's some really interesting stuff specifically about calcium channel blocker overdoses.
00:19:04
Speaker
And...
00:19:06
Speaker
And pretty good outcomes in cannulating.
00:19:09
Speaker
I mean, I and I can think of we've done three.
00:19:12
Speaker
And I remember one of them, profound shock, profound shock and was wide awake, not intubated.
00:19:18
Speaker
And I actually consented the family.
00:19:21
Speaker
But I remember speaking to her as I was doing the procedure.
00:19:24
Speaker
Right.
00:19:25
Speaker
Pretty, pretty dramatic.
00:19:26
Speaker
And another same thing.
00:19:27
Speaker
He was intubated, but he was totally awake, profound shock.
00:19:30
Speaker
And we and they did quite well.
00:19:32
Speaker
So for those scenarios, yeah, we've used it for sure.
00:19:35
Speaker
Perfect.
00:19:35
Speaker
And that's the same thing, right?
00:19:36
Speaker
The drug is going to go away and they're going to get reversible.
00:19:40
Speaker
So like that's the one you want to do it with.
00:19:42
Speaker
Excellent.
00:19:43
Speaker
And obviously getting a good history is going to be important because you don't have a lot of time, but like you mentioned,
00:19:49
Speaker
So, unwitnessed cardiac events, prolonged low flow or actual no flow times are all going to be the determinants that you probably would say, no, this is not a good candidate.
00:20:03
Speaker
So, that's very important.
00:20:05
Speaker
Once you have a patient who in the ICU and the OR or in the ED, I guess, let's talk about in hospital cardiac arrest to start.
00:20:14
Speaker
It has a cardiac arrest.
00:20:15
Speaker
You start ACLS.
00:20:16
Speaker
You start CPR.
00:20:18
Speaker
You're not getting to the point.
00:20:20
Speaker
You get called.
00:20:21
Speaker
You're thinking of ECMO.
00:20:23
Speaker
Can you tell us a little bit more about...
00:20:26
Speaker
how it really happens.
00:20:27
Speaker
So let's start with the cannulation and what's the appropriate timing.
00:20:31
Speaker
I'm sure it's as soon as possible, but how do you manage timing?
00:20:35
Speaker
Who cannulates?
00:20:37
Speaker
Where do you cannulate?
ECPR Procedure and Team Coordination
00:20:38
Speaker
And what's the preferred vascular access?
00:20:41
Speaker
That's a lot of questions.
00:20:44
Speaker
It is.
00:20:45
Speaker
All right.
00:20:45
Speaker
You got to keep me on track when I start to wander.
00:20:48
Speaker
So what happens at our institution, and we're a relatively young ECMO program, and we do, I would say, 40 to 50 cases a year.
00:20:59
Speaker
That's BV, VA, and ECPR.
00:21:01
Speaker
And it's taken us some time, but we have what's called a code ECMO program.
00:21:05
Speaker
So when there's a patient who, and this could be any ECMO, we think that needs to be cannulated, anyone can call the operator.
00:21:14
Speaker
And there's a handful of people that get alerted.
00:21:16
Speaker
So it is the intensivist that's on ECMO call.
00:21:20
Speaker
We have a tiered
00:21:22
Speaker
uh cannulation strategy where there's some providers who can do vb some that can do va and some that can do ecpr and that comes with experience and so you have to have if it were ecpr one of them immediately available which isn't always the case right so we can't do it all the time um
00:21:40
Speaker
Perfusion gets notified.
00:21:43
Speaker
And so they get notified.
00:21:45
Speaker
And then usually our advanced heart failure, there's some other consultants that don't necessarily come.
00:21:50
Speaker
And then our critical care nurses in our main ICU get notified and they show up with the tools and equipment.
00:21:57
Speaker
We bring a TEE to every cannulation.
00:21:59
Speaker
And we go anywhere in the hospital.
00:22:01
Speaker
So preferred would probably be the ICU, although we've been doing more and more cases in the ER.
00:22:08
Speaker
And I know you said in hospital, but sometimes patients sitting in the ER do it.
00:22:12
Speaker
And so I would consider that in hospital, right, even if they're physically in the emergency department.
00:22:19
Speaker
And so we call and we show up.
00:22:21
Speaker
I think it's really important that there is the CPR team.
00:22:26
Speaker
And then there's the ECMO team.
00:22:27
Speaker
And these are separate teams functioning differently.
00:22:30
Speaker
So the CPR team is doing all the stuff you need to do for ACLS.
00:22:34
Speaker
And that when you're the ECMO attending and deciding to can you later or not, you really shouldn't also be trying to run the code.
00:22:41
Speaker
You need definitely distinct teams.
00:22:43
Speaker
And you do as quick as you can look at the chart and understand.
00:22:48
Speaker
You find if there is someone, a surrogate.
00:22:52
Speaker
And honestly, sometimes there is not an immediate and you have to make a decision, but ideally you're able to speak to a surrogate.
00:22:58
Speaker
And then we get ready to cannulate.
00:23:01
Speaker
Does that do you need more details in terms of that?
00:23:03
Speaker
Or is that that kind of makes sense?
00:23:06
Speaker
No, I think that that tells, I mean, the response and who cannulates.
00:23:09
Speaker
And in terms of location, obviously, you kind of go where the patient is, right?
00:23:13
Speaker
But but when you look at the literature, people talk about ED versus OR versus cath lab versus ICU.
00:23:19
Speaker
But you don't move the patient from the ICU or from the ED to the OR, the cath lab to cannulate.
00:23:25
Speaker
Correct.
00:23:26
Speaker
Correct.
00:23:27
Speaker
We don't move them.
00:23:28
Speaker
We don't move them and we do it wherever we can.
00:23:31
Speaker
You know, I think the Inception trial, which is the most recent trial looking at ECPR outcomes, the time from hospital arrival, now this was out of hospital to cannulation, was somewhere in the realm of 15 minutes, right?
00:23:44
Speaker
So, fluoro is really helpful to see where your wires are.
00:23:48
Speaker
TEE is great to see if there's an identifiable cause of the arrest.
00:23:53
Speaker
and can also help to make sure that the wire's in the appropriate place.
00:23:57
Speaker
But yeah, no, we don't move the patient where they are is where we do it.
00:24:02
Speaker
And then how does it... Go ahead.
00:24:03
Speaker
You lose the floral support, but obviously you gain on the time, which is super important.
00:24:09
Speaker
Yeah, yeah.
00:24:11
Speaker
You know, if...
00:24:13
Speaker
But that's kind of, honestly, that happens for any of the ECMO cannulations, even VV.
00:24:18
Speaker
If they're sick enough that they need it, they're not stable to move from one place to an ICU.
00:24:24
Speaker
So we tend to cannulate wherever they are and then go from there.
00:24:28
Speaker
Sometimes the pace of VA is a little different, and you can move a kind of semi-urgent patient to a better location that needs VA.
00:24:38
Speaker
Yes.
00:24:39
Speaker
And obviously, the OR and the cath lab might also be places where people are rest.
00:24:43
Speaker
So that might be the site where you do the cannulation for that reason.
00:24:47
Speaker
Yep.
00:24:48
Speaker
We've done a couple massive PEs, you know, orthopedic procedures and big emboli, and then developing massive PE that we've cannulated in the operating room.
00:24:57
Speaker
Okay.
00:24:57
Speaker
Now, we talked a little bit about who cannulates the location, the timing, and you mentioned inception.
00:25:05
Speaker
So as soon as possible, is there a cutoff where you might just say, okay, we've been trying to cannulate.
00:25:11
Speaker
I mean, we're done.
00:25:13
Speaker
We can't get it.
00:25:17
Speaker
I think it all just depends on each patient, right?
00:25:19
Speaker
If you're seeing signs of life, if you have high quality CPR, your end title is acceptable.
00:25:24
Speaker
If I think age plays a big role, right?
00:25:29
Speaker
Honestly.
00:25:30
Speaker
And I think there's no dead set cutoff.
00:25:33
Speaker
I do believe that low flow time should be under 40 minutes, ideally.
00:25:38
Speaker
And I think that's a
00:25:42
Speaker
is the amount of time it takes to establish flow.
00:25:45
Speaker
Excellent.
00:25:46
Speaker
And in terms of the preferred vascular access sites, what do you usually do?
00:25:50
Speaker
It's going to be VA, obviously, because you're doing both circulatory and oxygenation support.
00:25:57
Speaker
But what do you do?
00:26:00
Speaker
Yeah, so it's going to be fem-fem always for VA.
00:26:04
Speaker
It's always going to be fem-fem in this scenario.
00:26:06
Speaker
And I will say, ideally, when we cannulate for VA, the drainage, which is the vein,
00:26:14
Speaker
is we always say and you'll you'll read in some literature talks like inflow and outflow which gets confusing to me so we just refer to drainage and return always respective to the patient of course so the drainage in the vein is a multi-strate multi-stage cannula and then the arterial return um and so
00:26:32
Speaker
What we prefer to do for VA is have them on different sides.
00:26:36
Speaker
And that a lot of that has to do with venous congestion, you know, blocking the vessels.
00:26:41
Speaker
And it's been shown if you have them on different sides, so one on left, one on right.
00:26:46
Speaker
There is less of chance of limb ischemia.
00:26:50
Speaker
But when you're doing ECPR, I'll be honest, you know, I'm sure we've most people here have done have done a femoral a line or any a line and you get that stick and you see the wire and you put the cannula in and you get this beautiful blood pulsatile.
00:27:06
Speaker
bright red blood pulsating, right?
00:27:08
Speaker
And you're like, yes, I'm in the artery, right?
00:27:10
Speaker
Or maybe you're trying to do a triple lumen in the IJ and you accidentally hit the carotid.
00:27:13
Speaker
You're like, oh no, I'm in the artery.
00:27:15
Speaker
But we've all kind of know what that looks like.
00:27:17
Speaker
You don't really get that with eCPR, right?
00:27:20
Speaker
Because the heart's not working, they're dead.
00:27:23
Speaker
And so sometimes with CPR, you'll see pulsation, but you don't always know.
00:27:28
Speaker
And so what we do is I like to do the same side, because then when I have two wires in, assuming I go at
00:27:37
Speaker
vein and the lateral ones probably in the artery.
00:27:39
Speaker
So I know if you do opposite sides, you're always worried that you're in vein and vein or even artery and artery, right?
00:27:48
Speaker
Makes sense.
00:27:49
Speaker
So you usually get what you can, right?
00:27:53
Speaker
But usually your practice is to go on the same side, and it's always going to be femoral for these patients.
00:28:00
Speaker
Perfect.
00:28:00
Speaker
So I stick one.
00:28:02
Speaker
I stick one.
00:28:03
Speaker
I look at where the wire – I get a wire in.
00:28:04
Speaker
I look to see where the wire is, and then I see if there's a vessel lateral or medial to it, and that tells me if I think I'm in the vein or the artery.
00:28:12
Speaker
Generally, I like to stick the artery first if I can, but really whatever is – you do what you can.
00:28:18
Speaker
And then we go from there.
00:28:19
Speaker
There's a lot of talk, and maybe this is, maybe I should wait to do this, but a lot of talk about reperfusion cannula.
00:28:25
Speaker
And if you should do it or not do it, we never put a reperfusion cannula in during an eCPR case.
00:28:29
Speaker
That always will come later after they're cannulated.
00:28:33
Speaker
And that's a little different operation when you're doing kind of a semi-urgent or elective VA case.
00:28:38
Speaker
For sure.
Improving Outcomes After ECPR
00:28:39
Speaker
So basically, you get the cannulas in, you set the patient up on the circuit, and what happens then?
00:28:45
Speaker
I mean, even though there's not immediate ROC, it doesn't matter anymore, right?
00:28:51
Speaker
Right.
00:28:51
Speaker
So a lot of times you put them on.
00:28:54
Speaker
And they are non-pulsatile.
00:28:58
Speaker
So they're non-pulsatile.
00:28:59
Speaker
That means you're not, you know, you'll get a MAP, but it's just flat.
00:29:03
Speaker
You're not going to get a systolic and diastolic.
00:29:05
Speaker
Or if you do, there's like not a huge difference between it.
00:29:09
Speaker
It's sometimes unlikely you're even going to have pulse ox because without the pulsation, it's hard for it to read.
00:29:14
Speaker
And so you still titrate your vasopressors.
00:29:18
Speaker
You kind of get flow going.
00:29:19
Speaker
And if they're flowing at three, four liters, you're happy.
00:29:22
Speaker
You titrate your sweep kind of basically.
00:29:24
Speaker
on how acidotic you think they are obviously use your vent the best you can and then you start to look to see if there's reversible reasons for why it happened and what's what's neat and what kind of probably the beauty of eCPR is is not only does it restore perfusion to all of your organs so that it decreases the chance of you know gut ischemia or noctic injury or liver you know shock liver but it also increases your coronary perfusion pressure so all of a sudden you're more likely to
00:29:55
Speaker
So a lot of these patients once you get flow will then start contracting and get ROSC and How do you manage kind of the next 24 48 hours?
00:30:06
Speaker
Is there anything that you do that's unique to eCPR?
00:30:11
Speaker
So number one figure out what caused it and see if you can reverse that right so
00:30:17
Speaker
So go to the cath lab if you need to, kind of determine that.
00:30:21
Speaker
I think that's number one.
00:30:22
Speaker
Number two, we like to get, we like to do CTs on all of these patients and understand if there's other injury or other things happening.
00:30:29
Speaker
You know,
00:30:32
Speaker
A lot of patients have neurological injuries, so understanding that's important.
00:30:36
Speaker
And then we kind of looked out for the big complications and the big concerns.
00:30:40
Speaker
And I think the three main concerns or immediate complications are limb ischemia.
00:30:46
Speaker
So we really pay attention to the perfusion of that leg with the cannulas in it.
00:30:50
Speaker
And we can talk about kind of what we do and how we do and what we do about it.
00:30:54
Speaker
Number two, we really think about the left ventricle and if it needs to be unloaded.
00:30:59
Speaker
I think for the most part, if the LV is down, we unload almost all of them.
00:31:05
Speaker
And there's debate whether that should be a balloon pump or an impella.
00:31:08
Speaker
I think for us, it's usually an impella.
00:31:11
Speaker
And then third, we always worry about north-south or Harlequin syndrome and making sure we address that to avoid cerebral hypoxemia.
00:31:19
Speaker
Could you expand a little bit on the north-south syndrome just for those who are not as familiar with ECMO?
00:31:24
Speaker
Yeah, yeah.
00:31:26
Speaker
So I'll try to kind of explain it the way my simple mind thinks about it.
00:31:30
Speaker
But the way I think about it is you have an arterial cannula sitting in the femoral artery.
00:31:35
Speaker
It's going counter flow, right?
00:31:37
Speaker
And it's pumping it three or four liters up the femoral artery and the aorta, right?
00:31:43
Speaker
And then you have...
00:31:45
Speaker
your native heart.
00:31:46
Speaker
And so when it's non pulsatile, there's no competing flow out of the heart.
00:31:52
Speaker
It's and so that good oxygenated blood is bypassing the heart and going up to the brain, making sure your brain is oxygenated, making sure your upper extremities are oxygenated, right?
00:32:03
Speaker
That's why we all and the way we make sure is we always do a right radial a line because it's the farthest from that.
00:32:09
Speaker
So if there's good PO2 there, then there's probably good PO2 in the brain and everywhere else.
00:32:14
Speaker
But as that heart starts to function again and starts to beat, it contracts, and now all of a sudden there's forward flow that's competing in what's called a mixing cloud.
00:32:23
Speaker
And so if that mixing cloud moves further down the aorta as the heart is gaining strength—
00:32:31
Speaker
all of a sudden that nice easy pathway of oxygen oxygen blood up to the brain doesn't happen and so if your lungs are okay not a big deal right because that blood that's coming out of the heart is well oxygenated from the lungs and it'll go north and it'll take care of everything and we have this we have these tissue perfusion monitors that kind of tell you what your what your oxygenation is and tissue oxygenation is and that's how we tell if there's a problem as well as the right radial a line right so
00:33:00
Speaker
It's not a problem, but where it becomes a problem is if you develop kind of LV ballooning out and pulmonary edema.
00:33:06
Speaker
And keep in mind, these patients almost, they take some sort of renal injury, right?
00:33:11
Speaker
They get some ATN.
00:33:13
Speaker
They're getting tons of press or tons of volume.
00:33:15
Speaker
So it's really common to get pulmonary edema.
00:33:17
Speaker
And now if bad blood, bad deoxygenated, not well-oxygenated blood's coming out of the heart and going north, then you develop something called north-south or Harlequin syndrome.
00:33:27
Speaker
So you need the heart to be pulsating for that to happen, obviously, which is maybe an advantage short term of a non-pulsatile patient on ECPR.
00:33:36
Speaker
But it seems that there are certain things that are potential or that you need to manage differently where the patient has ROSC or not.
Challenges: North-South Syndrome and Mortality Rates
00:33:47
Speaker
And that's one of them.
00:33:49
Speaker
Are there other things that you do while they have no pulsations versus when they have pulsations that might be of importance?
00:33:57
Speaker
Yeah, I mean, I think the biggest concern is that LV ballooning out, right?
00:34:00
Speaker
So if they're not pulsating and there's no forward flow, then they'll get thrombus in the left ventricle.
00:34:05
Speaker
And if that starts to happen, it's a death sentence.
00:34:08
Speaker
You're in big trouble, right?
00:34:10
Speaker
And so that's what we talk about LV unloading, which is essentially a balloon pump or an impella that's pulling blood to make sure that that LV stays decompressed as much as you can.
00:34:21
Speaker
So I think that's a huge focus.
00:34:22
Speaker
Yeah.
00:34:24
Speaker
That's probably the biggest difference for pulsating versus non-pulsating.
00:34:27
Speaker
And that's an important distinction because sometimes for people who are not as familiar with ECMO, you might think, well, why are you adding a balloon pump?
00:34:34
Speaker
Why are you adding an impellant?
00:34:36
Speaker
You're already on ECMO, right?
00:34:37
Speaker
And it is, they do different things and it's because you're trying to unload the LV.
00:34:44
Speaker
What are other complications?
00:34:46
Speaker
You mentioned, obviously, complications that you need to manage.
00:34:51
Speaker
Anything with infection or neurological complications that you manage with these eCPRs in particular?
00:34:58
Speaker
Yeah, I'm trying to think.
00:35:00
Speaker
So, infection is just your normal situation.
00:35:05
Speaker
how you would normally handle infection.
00:35:07
Speaker
Obviously, you have large-bore cannulas that are at increased risk.
00:35:11
Speaker
A lot of these patients are, all these patients have a temperature water bath, then you have, so a lot of them don't have fevers, right?
00:35:19
Speaker
Because the blood flow is leaving the body at whatever, five liters a minute, and then going through a water bath that's making it 98.6 degrees and then going back to the patient.
00:35:28
Speaker
Kind of like if you think about your CRT patient, a lot of them becomes hypothermic because it's leaving the body.
00:35:33
Speaker
If you don't have that water bath, then they will
00:35:35
Speaker
become, they'll become hypothermic.
00:35:37
Speaker
So they don't necessarily mount a fever.
00:35:39
Speaker
So we're much more sensitive to bandemia.
00:35:41
Speaker
And I think our trigger to give antibiotics is, is, is pretty low.
00:35:45
Speaker
We, we, we do it pretty quickly.
00:35:47
Speaker
So we that neurological,
00:35:51
Speaker
The incidence of neurological injury in these patients is really high.
00:35:55
Speaker
We think a lot about the rate of PCO2 change, and this is probably more for VV, but certainly for VA too, and that we don't want there to be a huge abrupt drop in their PCO2 when you put them on.
00:36:08
Speaker
So we're a little cautious about how we use the sweep and obviously get them out of life-threatening acidosis, but we're a little cautious about it because a rapid drop in PCO2 has been associated with poor neurological injury.
00:36:22
Speaker
outcomes in terms of brain bleeds and swelling, etc.
00:36:26
Speaker
So we're really aware of that.
00:36:28
Speaker
And I think the last one is a limb ischemia that I talked about.
00:36:32
Speaker
And so we will put reperfusion cannulas in if we think that there's a chance that there's limb ischemia not getting good distal blood flow where the cannula is.
00:36:43
Speaker
Let's talk a little bit about how we wean eCPR.
00:36:48
Speaker
And I guess there's two big potential trajectories here.
00:36:54
Speaker
We find a reversible cause, things are getting better, and we move forward versus, and we'll talk about that first, versus
00:37:02
Speaker
We don't find a cause.
00:37:04
Speaker
We're not getting pulsations.
00:37:06
Speaker
Or there's some other disaster that really indicates that this is not going as we had hoped.
00:37:12
Speaker
So when patients are progressing well, how do you think about weaning the eCPR support?
00:37:20
Speaker
Yeah, so that's a great question.
00:37:23
Speaker
And essentially what happens is you'll see good contractility, your vasopressors will wean off, and you will just be on flow.
00:37:33
Speaker
And we do what's called a ramp trial where we will, under echo guidance, usually TEE, but not always, and we will slowly decrease our ECMO flow.
00:37:44
Speaker
to the point where we have to keep some flow we don't want the circuit to clot off but that they become more and more dependent on their native cardiac function and if their basal pressors don't change and their map stays good and we look at the squeeze you know they're not developing right heart failure as we're decreasing and you know and unloading because if you think about it when you're flowing you're draining
00:38:04
Speaker
from the IBC.
00:38:05
Speaker
So that's the perfect way to offload the RV.
00:38:07
Speaker
And as I'm flowing less and less, the RV has to be able to handle it.
00:38:10
Speaker
And so if I can see that they're handling it well, then that would be the trigger to say, okay, I think it's time to decannulate.
00:38:18
Speaker
It's really not much more scientific than that.
00:38:21
Speaker
No, and I think it's important, obviously, just to appreciate how it happens.
00:38:26
Speaker
Now, what about
00:38:27
Speaker
Patients who are not doing well.
00:38:29
Speaker
So is there like a no ROSC time that tells you this is really not going to work or it depends also on what you found?
00:38:38
Speaker
If you have no clue why they coded and they're not having ROSC is very different than you think you know what happened, but you still don't have ROSC versus you have ROSC, but there's other complications.
00:38:48
Speaker
Can you talk about what's projected when patients don't do very well?
00:38:54
Speaker
You know pretty quickly.
00:38:55
Speaker
The tempo of VA and ECPR is much different than the tempo of VV.
00:38:59
Speaker
And you know really quickly.
00:39:01
Speaker
I'm thinking about a young woman that we took care of who had toxic shock syndrome and had developed severe cardiomyopathy, and we put her on...
00:39:11
Speaker
on va and despite that and doing all the appropriate things her lactate kept going up she had shock liver she was in dense atn she was really acidotic right you you know pretty quickly that it's not going to work um and i think this is probably one of the main reasons too that it's just so important to have family and consenting consentable um someone to consent because
00:39:35
Speaker
Part of our consent is to say, hey, if things are not going well, we don't want to hurt this person more.
00:39:41
Speaker
We'll let you know, and we will let you know that it's time to stop, and you kind of have to buy into it.
00:39:48
Speaker
Obviously, it's a joint decision, but we found that it's really important to be up front and say we may come to you and say that this has failed, in which case we need to stop together.
00:39:58
Speaker
When you have patients who neurologically are not recovering, so let's say you fix the heart or you have ROSC, do you think of neuroprognostication any differently than you would in another cardiac arrest patient?
00:40:15
Speaker
Yeah, not really.
00:40:16
Speaker
I mean, it's important if you're going to be an ECMO center, it's important to have your own ECMO-specific process.
00:40:22
Speaker
um, ECMO specific brain death criteria.
00:40:24
Speaker
Uh, but you can do apnea tests now in VV, you can turn off the sweep, right?
00:40:30
Speaker
And that's okay.
00:40:31
Speaker
But if they're on VA, you have to keep the sweep gas on.
00:40:34
Speaker
Um, the sweep is what kind of facilitates CO2 removal.
00:40:38
Speaker
And if your sweep is off, you would essentially be putting the oxygenated blood, um,
00:40:44
Speaker
into the arterial system.
00:40:45
Speaker
So you have to keep the sweep on.
00:40:47
Speaker
But no, you can do acne testing.
00:40:48
Speaker
We tend to do imaging usually.
00:40:51
Speaker
But the process to declare someone brain dead is very similar.
00:40:56
Speaker
And in terms of those patients who have severe anoxic injury but are not brain dead, follow the same algorithm you use for other post-cardiac arrest survivors?
00:41:06
Speaker
Yeah.
00:41:07
Speaker
Yep.
00:41:08
Speaker
Yep.
00:41:08
Speaker
Same thing.
00:41:08
Speaker
So we do TTM.
00:41:10
Speaker
We do TTM through the circuit.
00:41:12
Speaker
We will get imaging the same way we normally do.
00:41:14
Speaker
We talk to the family the same way we normally do.
00:41:18
Speaker
You know, we obviously in those scenarios, we kind of if it's capable to get them off MCS, we get them off MCS to simplify things.
00:41:25
Speaker
But no, all the same way.
00:41:27
Speaker
Yeah.
00:41:28
Speaker
And in general, because you mentioned that you, you know, pretty quickly, have you found or the registries suggest or show that ECPR runs are just shorter on average than VV runs for sure.
00:41:44
Speaker
And then other VA runs.
00:41:47
Speaker
Oh, I don't know.
00:41:47
Speaker
I think for sure.
00:41:48
Speaker
I mean, it,
00:41:49
Speaker
I think it's shorter than VV without a doubt, right?
00:41:52
Speaker
We've all seen those studies on 100 plus day VV runs.
00:41:56
Speaker
And VA in general is much shorter.
00:41:58
Speaker
But yeah, I would assume that eCPR, that's probably just because the mortality is high.
00:42:02
Speaker
So you have a mortality time bias.
00:42:04
Speaker
And so in general, the median time is going to be shorter.
00:42:09
Speaker
As we try to put things together at the bedside, what are some common pitfalls that you would recommend clinicians avoid as they are thinking of ECPR or learning about ECPR or starting an ECPR program at their institution?
00:42:25
Speaker
Yeah.
00:42:26
Speaker
I...
00:42:28
Speaker
I knew you were going to ask me that.
00:42:29
Speaker
And I was trying to think of the best way.
00:42:31
Speaker
And I, you know, I, I love where I work and I love Cooper and, and I'm sure, I'm sure you have fond memories there and it's, it's amazing.
00:42:41
Speaker
And I should, and I love that we as the intensivist group are the ones who are at the bedside doing this.
00:42:47
Speaker
But I think it's really important to highlight just how important the rest of your consultants are.
00:42:52
Speaker
There's no way we could do this without really supportive vascular surgeons that help us with the decannulation of the arterial cannula, that help us with the...
00:43:02
Speaker
The limb complications, which happen, I think I cited, you know, a third of the patients in ECPR have some sort of ischemia or limb complication to the point where vascular surgery is consulted on every VA patient right after cannulation, regardless.
00:43:17
Speaker
So important to have your CT surgeons and obviously your interventional cardiologist to help with the cath or the, um,
00:43:24
Speaker
Or the impella or the balloon pump based on what you decide to do.
00:43:28
Speaker
And not to mention the advanced heart failure.
00:43:31
Speaker
So really just because the cannulation part itself is is one of the easier parts of managing these patients.
00:43:39
Speaker
and it's just respecting and having all the team there to do it.
00:43:42
Speaker
So that would be one.
00:43:43
Speaker
And number two, I think the pitfall is it's so easy to, the hardest decision is to not cannulate.
00:43:50
Speaker
And I'm telling you, like, I have so many memories where I'm at the bedside and they seem young and it's a V-fib arrest and, you know, but we are missing some information and the ECMO circuits there and you're ready to go.
00:44:03
Speaker
And then it's just so important to take a moment really
00:44:06
Speaker
dive deep and try to figure out if it's a good idea or not.
00:44:10
Speaker
Um, because I've been in those scenarios where I've cannulated and then found out more and they've had bad neurological outcomes.
00:44:16
Speaker
And I was like, shoot, you know, the, the discomfort and the, the, it's just so much more painful for the family.
00:44:22
Speaker
So really take time to make the decision correctly.
00:44:25
Speaker
That would be probably number two.
Role of Expertise in eCPR Success
00:44:28
Speaker
And, you know, I should say, like, be cautious before jumping into eCPR.
00:44:33
Speaker
It's very clear that the more experienced you are, the better the outcomes are more than any other type of ECMO.
00:44:39
Speaker
It's so it's directly correlated.
00:44:42
Speaker
So if you don't have the volume or the expertise, then then I would be cautious to jump into it.
00:44:47
Speaker
And with that said, like.
00:44:49
Speaker
I know I'm giving you a lot, but you should really know, like spend time with the circuit.
00:44:54
Speaker
Things happen, and so the more you can spend at the circuit, understanding how to put it together, understanding how to set up the room for the cannulation, understanding if there's a problem, what to do, the better.
00:45:05
Speaker
It's just really all about touches.
00:45:08
Speaker
And clearly, obviously, this is a super high pressure, high stakes, but also time sensitive intervention.
00:45:15
Speaker
So making sure that you orchestrate the team in an appropriate way as you build, because nobody has a high volume ECPR program on day one, right?
00:45:26
Speaker
You have to start somewhere.
00:45:27
Speaker
And as we mentioned, I do believe that
00:45:30
Speaker
MCS in all its forms is increasing throughout the country and it's more likely to be at your program if you don't have it now and in your future.
00:45:40
Speaker
So it's very important.
00:45:42
Speaker
Any pearls of wisdom?
00:45:43
Speaker
I mean, you've shared some of them, but more things that you really think that you should start there.
00:45:51
Speaker
Oh, wow.
00:45:52
Speaker
I think I just, in my last vomit of words, I think I gave you all of the pearls of wisdom.
00:45:59
Speaker
Yeah.
00:46:01
Speaker
You know, just, as I said, read about it, think about it, question it.
00:46:07
Speaker
I would say, I think that's the biggest thing we've learned as we've kind of grown our program and started to publish on the topic and really think about it, is that it's such a new field.
00:46:17
Speaker
It really is.
00:46:18
Speaker
There are some dogmas out there that...
00:46:21
Speaker
that you should question, you know, like COVID brought us VV and we published on how medical intensivists could do VV successfully.
00:46:30
Speaker
And that was pretty novel.
00:46:32
Speaker
And now it's becoming more and more common.
00:46:33
Speaker
So I would everything you read, just take with a grain of salt and really think about it.
00:46:39
Speaker
Because the field is definitely is young.
00:46:42
Speaker
Absolutely.
00:46:43
Speaker
Anything in research that's exciting you up on the horizon, specifically with eCPR?
00:46:51
Speaker
Yeah, I don't know.
00:46:53
Speaker
I think it's all about patient selection.
00:46:54
Speaker
I mean, even these studies, the ones I cited, the biggest end was 300, right?
00:46:58
Speaker
So like with everything cardiac arrest, I think that the out-of-hospital versus the in-hospital are two very distinct populations.
00:47:07
Speaker
And even if you look at research on in-hospital cardiac arrest in general, it's lacking, right?
00:47:13
Speaker
It's definitely not as robust as out-of-hospital cardiac arrest.
00:47:16
Speaker
So understanding that, and I think the difference between V-fib and PES
00:47:21
Speaker
They're just, we lump them as one group of patients, and I think they're not.
00:47:26
Speaker
And so really, it's probably just patient selection and understanding who would benefit from what treatment modality, right?
00:47:33
Speaker
Absolutely.
00:47:34
Speaker
And patient selection is important for every therapy, but especially you have two factors that...
00:47:41
Speaker
are particular about eCPR.
00:47:43
Speaker
Number one is these patients to begin with have a very bad outcome, all comers.
00:47:48
Speaker
And number two, it's a super high resource intervention, right?
00:47:52
Speaker
Very invasive, very high resource.
00:47:54
Speaker
So trying to find the right patient that can, you can make a difference is important, but
00:47:59
Speaker
based on what you share with us, Adam, it is clear in your experience, but also in the literature that for some patients, for the right patient, this might be a game changer.
00:48:08
Speaker
This might be the difference, right?
00:48:10
Speaker
And that's where, who you want to try to identify.
00:48:13
Speaker
Yeah.
00:48:14
Speaker
Yeah, definitely.
00:48:15
Speaker
Definitely.
00:48:16
Speaker
And, um,
00:48:17
Speaker
I wanted to share a story with you.
00:48:19
Speaker
I was hoping I could find the right time.
00:48:20
Speaker
Maybe now I can share a case that I think is kind of powerful and demonstrates it.
00:48:26
Speaker
This one sticks with me for a long time.
00:48:28
Speaker
I've kind of alluded to it throughout this hour.
00:48:31
Speaker
You know, I was this was kind of before we really did eCPR.
00:48:35
Speaker
We were diving into the VA world and I was called to the trauma bay.
00:48:41
Speaker
And it was a young woman who had a motor vehicle accident and had what we thought was just pulmonary contusions.
00:48:49
Speaker
And I was called to cannulate for BP.
00:48:51
Speaker
And by the time I arrived, which was pretty quick, she had had a cardiac arrest.
00:48:56
Speaker
She went to CAT scan and came back and had a cardiac arrest.
00:48:59
Speaker
And so we decided to cannulate her for VA.
00:49:02
Speaker
And unfortunately, she had suffered a devastating neurological injury too.
00:49:08
Speaker
And so she progressed to brain dead pretty quickly.
00:49:10
Speaker
And kind of what stuck with me is, number one, most trauma patients are going to be
00:49:16
Speaker
excluded because they're either bleeding or have neurological injury.
00:49:19
Speaker
So you got to be careful there.
00:49:22
Speaker
But what was kind of amazing about the case, and I think highlights just you never really know how things are going to go, is that she ended up progressing to brain death.
00:49:30
Speaker
And her, I think it was her nephew or no, maybe her cousin was was waiting for a liver and a kidney.
00:49:39
Speaker
donation.
00:49:39
Speaker
He's been listed at a local transplant center and she was a match and so she ended up being progressing to brain death, being declared brain death and then going and being procured and he got both of her organs.
00:49:50
Speaker
And so
00:49:52
Speaker
I guess I think that just highlights sometimes you don't know where things are going or what's going to happen and just do the best you can for every patient, right?
00:49:59
Speaker
Yeah, I know it's a powerful story.
00:50:00
Speaker
And a reminder for intensivists that even in the patients who we have who are declared brain death or who are going to be made a comfort care because they had some devastating injury, there is still the possibility of using their organs and their donors to
00:50:16
Speaker
to save another life, right?
00:50:18
Speaker
And even though that patient's usually not under our care, we have a responsibility to those patients as well.
00:50:24
Speaker
So it is a very powerful, powerful story and a great reminder for all of us.
00:50:31
Speaker
Adam, we'd like to close the clinical discussion with a couple of questions that are unrelated to our clinical topic.
00:50:38
Speaker
Would that be okay?
00:50:40
Speaker
Yeah, of course.
00:50:40
Speaker
Of course.
00:50:41
Speaker
So the first question relates to books and what book has influenced you the most or what book have you gifted often to other people?
00:50:50
Speaker
Oh, wow.
00:50:54
Speaker
So I was prepared for this after listening to your podcast.
00:50:56
Speaker
And so I think I could go a bunch of different directions.
00:50:59
Speaker
Admittedly, I used to read a lot more and I know you're a prolific reader.
00:51:02
Speaker
And so I aspire to be like you.
00:51:04
Speaker
But the one that came to mind was...
00:51:09
Speaker
if you've read it um and it it will make you never want to prescribe an antibiotic again um so i can give you a little bit about it or i can just leave it at that whatever you prefer but perfect predators is an excellent read for those of us in the medical field i highly recommend it so i actually do believe i read it and uh because um it relates to a synodobacter correct
00:51:32
Speaker
Yes.
00:51:32
Speaker
Yes.
00:51:33
Speaker
And one of my dear friends, younger friends, was actually on the research team that started using, was it prions or?
00:51:44
Speaker
Bacteriophages, yeah.
00:51:45
Speaker
Bacteriophages.
00:51:46
Speaker
Yeah, and they gifted that book.
00:51:49
Speaker
So I will definitely, we'll leave it there, but I agree.
00:51:52
Speaker
It's a great read.
00:51:53
Speaker
So I will definitely leave it there and put it in the show link.
00:51:58
Speaker
So perfect predator.
00:51:59
Speaker
Awesome.
00:52:00
Speaker
Yeah.
00:52:01
Speaker
Yeah, you'll be convinced.
00:52:02
Speaker
I will say after you read it, you'll be convinced we're all going to die from gram-negative bacteria.
00:52:07
Speaker
And you'll finally wash your hands, right?
00:52:09
Speaker
That's right.
00:52:11
Speaker
Awesome.
00:52:12
Speaker
So is there something you could share with us that you have changed your mind about in the last couple of years?
00:52:19
Speaker
Yeah, so this one's easy.
00:52:20
Speaker
This one I knew you were going to come with, and the answer is succinylcholine.
00:52:25
Speaker
That's what I changed my mind about.
00:52:27
Speaker
And I know you probably wanted me to stay away from medical, but I grew up, always grew up in fellowship.
00:52:33
Speaker
That's a funny thing to say.
00:52:34
Speaker
In fellowship, I always used ROC.
00:52:36
Speaker
We would never, ever, ever use tuxilcholine.
00:52:39
Speaker
And honestly, I was just, and the reason was I was so, I remembered that
00:52:44
Speaker
Being a intern and arriving at a code of a young man with pancreatitis that got succinylcholine to get intubated and he was in renal failure and had hyperkalemia and died during that intubation and I attributed it to succinylcholine I said I would never ever use it.
00:53:02
Speaker
And then Brian Fuller came and gave a ground round at our institution at Cooper, and he talked about the awareness trial.
00:53:12
Speaker
And it it really struck me the number of patients that probably get registered.
00:53:16
Speaker
rock to be intubated and are still paralyzed and awake underneath.
00:53:21
Speaker
And it convinced me that I should always use succulent choline if I can.
00:53:24
Speaker
That PTSD for the survivors is bad enough that we should be very aware of that.
00:53:31
Speaker
Fascinating.
00:53:32
Speaker
And that is perfect.
00:53:33
Speaker
It's something you change your mind about.
00:53:35
Speaker
So that is an interesting one.
00:53:37
Speaker
So definitely, I don't think I really read the awareness trial.
00:53:41
Speaker
So I'm going to have to look into that.
00:53:43
Speaker
And the last question really is more of a closing statement.
00:53:49
Speaker
Is there anything you want our listeners to know?
00:53:51
Speaker
Could be related to medicine, could be outside of medicine?
00:54:00
Speaker
I don't know.
00:54:02
Speaker
There's so many things I could say.
00:54:06
Speaker
I think I'll make it a kind of
00:54:10
Speaker
apply to medicine still, I think it's easiest for me.
00:54:13
Speaker
And I was trying to think about like specifically being intensivists and what we offer.
00:54:18
Speaker
And I think my piece of advice and something that took me a while to realize is that by far our biggest attribute is being available.
00:54:26
Speaker
And that I found the physicians, the intensivists that I think do the best are not the ones that they're all brilliant and proceduralists and can do all the things, but the ones that realize that our true value is being available at the bedside whenever the patient needs us.
00:54:41
Speaker
being the communicator between consultants and kind of putting our ego away and realizing that, you know, we need to ask for help and get people on board and just get the team moving in the right direction.
00:54:52
Speaker
So that would be my advice, especially to young people who are going into the field.
00:54:55
Speaker
It's just like that's what we bring is always being available.
00:55:01
Speaker
And I think that's something to be proud of.
00:55:03
Speaker
That's a perfect place to stop.
00:55:06
Speaker
Adam, I want to thank you for sharing your expertise and your time with us.
00:55:10
Speaker
Definitely learned a lot about ECPR and that we'll have to look at that awareness trial, but also highly recommend our listeners to read Perfect Predator and hope to have you back on the podcast soon to talk about other fascinating topics related to the practice of critical care medicine.
00:55:28
Speaker
Thank you.
00:55:29
Speaker
Thank you, Sergio.
00:55:31
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:55:34
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:55:40
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:55:45
Speaker
To learn more, visit www.soundphysicians.com.